Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

PARAQUAT TONGUE: CASE OF PARAQUAT POISONING AND REVIEW OF LITERATURE

We herein report a rare case of Paraquat poisoning which presented with multiple buccal mucosa and labial ulcers. He complained of burning pain in the mouth which increased on eating, along with difculty in complete mouth opening. The trismus progressed gradually from 4 ngers to 2 ngers breadth, over 2 days. The patient also had multiple episodes of vomiting with contents mainly being mucous secretions as the patient was nil per oral. Radiographic features including the imaging of the barium swallow of this case are discussed together with the pathomechanics of the poison. A comprehensive overview of the biochemistry and pharmacodynamics of Paraquat has been given as well. Understanding the mechanism of action of Paraquat will help to explain the manifestations of the poisoning and its subsequent treatment. Medical management was undertaken with the imperative step being the use of pulsatile steroid therapy. Supportive care and oral exercises were advised simultaneously to ensure optimum recovery. We looked at previously published literature to assess the proposed management protocols in the absence of a denitive antidote, leading to high mortality rates.</jats:p

GIANT INGUINOSCROTAL HERNIA - A RARE CASE MANAGED AND REVIEW OF LITERATURE

Massive inguinoscrotal hernias are rare hernias that extend below the midpoint of the inner thigh, in the standing position. We present a case of a 66- year-old patient with a very large irreducible bilateral direct inguinal hernia, without signs of obstruction or gangrenous changes. The patient was taken up for surgery under general anesthesia after optimizing the patient using preoperative incentive spirometry and nebulization. We used the laparoscopic transabdominal preperitoneal laparoscopic(TAPP) approach to reduce the hernial content which was followed by Lichtenstein's open bilateral inguinal hernioplasty. The patient was kept sedated and paralyzed on ventilatory support in intensive care for 2 days. Management of giant hernia is challenging due to various problems such as loss of domain, intraoperative cardiorespiratory complications, increase in intra-abdominal and intrathoracic pressures. Even after successful management recurrence is another complication faced when compared to other inguinoscrotal hernias. We describe laparoscopic reduction along with open bilateral inguinal hernioplasty as a viable technique in this patient followed by elective ventilation in the postoperative period. He did not require bowel resection as adequate abdominal relaxation is attained with this approach.</jats:p

Intestinal malrotation with midgut volvulus: associations and role of elective surgery in adults

Intestinal malrotation, a congenital anomaly of rotation of midgut, with paediatric dominant presentation is increasingly being observed in adult population. Here, the severity of presentation ranges from asymptomatic to life threatening midgut volvulus. Presentation with midgut volvulus, managed by an emergency surgery with definitive Ladd’s procedure is the current standard. Presently, there is no data to support elective repair in stable patients with chronic midgut volvulus. Management of asymptomatic adult with malrotation is also a topic of controversy with no recommended guidelines. We herein, present two cases of malrotation with midgut volvulus with initial conservative management followed by elective Ladd’s procedure. Rare associations like nutcracker phenomenon and pancreatitis were also observed in one of our patients. Our study aims to correlate our findings with the published literature, to understand these associations better and to review the need for an emergent operation for chronic midgut volvulus.</jats:p

Ganglioneuroma mimicking adrenal tumor

Ganglioneuromas arise from neural crest sympathogonia and are rare benign neurogenic tumors. The most common affected sites are posterior mediastinum and the retroperitoneum. They rarely affect adrenal glands. Ganglioneuromas often present as solitary, painless and slow growing mass and are benign in nature. These tumors are closely related to major vessels. Hence, surgical management of retroperitoneal pathologies may require multiorgan resection in order to achieve complete surgical resection while preservation of surrounding organs especially in case of benign tumors. We present a case report of a 21 year old male with a 12×10×10 cm size right sided retroperitoneal ganglioneuroma which on computed tomography (CT) mimicked adrenal tumor crossing the midline and abutting the aorta and splaying the inferior venal cava and renal vein. Present paper is an attempt to review the various surgical options available while dealing with these benign retroperitoneal tumors which are related closely to retroperitoneal organs and major vessels.</jats:p

A systematic review and network meta-analysis of interventions to preserve insulin-secreting beta cell function in people newly diagnosed with type 1 diabetes:results from randomised controlled trials of immunomodulatory therapies

Background: Type 1 diabetes is characterised by the immune-mediated destruction of pancreatic beta cells. We aimed to determine the effectiveness of immunotherapies for preserving residual beta cell function in newly diagnosed (stage 3) type 1 diabetes.Methods: Searches were carried out in MEDLINE, Embase, Cochrane CENTRAL and trial registries until 31st Jul 2024. RCTs of immunotherapies to preserve beta cells in newly diagnosed type 1 diabetes were included. Data were extracted using a bespoke, piloted extraction sheet. Risk of bias was assessed using Cochrane Risk of Bias Tool 1. A random effects network meta-analysis was undertaken in R. The primary outcome was C-peptide. Interventions were analysed by class.Results: Sixty trials were included (4597 patients, 32 intervention classes). Forty-one trials of 42 interventions were eligible for network meta-analysis. Eleven interventions demonstrated statistically significantly higher levels of C-peptide than placebo at 12 months, mesenchymal stem cells (autologous and Wharton’s jelly-derived cells), azathioprine, interferon-alpha (5000 IU), autologous dendritic cells, anti-TNF golimumab, low-dose ATG, 3 mg 1-course anti-CD3 teplizumab, baricitinib, cyclosporin and 9/11 mg 2-course anti-CD3 teplizumab but with substantial heterogeneity present (I2 = 66%). Azathioprine ranked highest (median ranking 3rd); however, rankings demonstrated relatively wide confidence intervals and thus uncertainty in exact rank order of near adjacent therapies. Risk of bias assessment identified poor reporting, particularly in older trials, but few studies demonstrated high risk overall.Conclusions: Eleven of 42 interventions demonstrated statistically significantly higher C-peptide levels than placebo at 12 months in the network meta-analysis. These results have identified the 11 most promising therapies trialled and help to direct future head-to-head clinical trials to support approvals for interventions to treat those newly diagnosed with type 1 diabetes. However, data for some interventions originated from small studies (mesenchymal stem cell therapies, azathioprine, autologous dendritic cells) and findings should be considered as hypothesis generating and interpreted with caution due to evidence heterogeneity.Systematic review registration: The protocol for the systematic review was registered on PROSPERO, the international database of prospectively registered systematic reviews (registration: CRD42018107904).<p/